Insurance Quote Request Form
Please complete the below form as completely as possible to enable us to provide accurate
Have you been working with a Capitol Agency team member? If so, tell us who:
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Brian Rauber
Leesa Payton
Michael Maxwell
Ed Cox
Byron Cleary
Darlene Reimer
Krista Williams
Amanda Lutz
Aaron Turner
Heather Jack
Buffy Deutsch
Rob Walton
Chris Goodwin
Other
How did you hear about us?
How did you hear about us?
*
Please Select
Customer Referral
Capitol Federal Mortgage
Web Search
Capitol Federal Marketing Email
Other
What insurance options are you looking to shop today?
*
Homeowners
Renters
Umbrella
Auto
Boat
Motorcycle/ATV/UTV
Business
Life
Medicare
Other
Named Insured (Applicant)
*
First Name
Last Name
Is there a co-applicant?
*
Yes
No
Co-Applicant
*
First Name
Last Name
Named Insured Date of Birth
*
/
Month
/
Day
Year
Date
Co-Applicant Date of Birth
*
/
Month
/
Day
Year
Date
Named Insured Driver's License #
*
Co-Applicant Driver's License #
Phone Number
*
E-mail
*
example@example.com
Name Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have You Lived At This Address For 5 Years Or Longer?
*
Yes
No
Prior Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Insurance
Who is your current home insurance carrier?
*
Year Built
*
Please Select
2025 (In construction)
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
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1986
1985
1984
1983
1982
1981
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1979
1978
1977
1976
1975
1974
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1971
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1928
1927
1926
1925
1924
1923
1922
1921
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1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900 or Before
Home Style
*
Please Select
1-Story/Ranch
1.5-Story/Split level
2-Story
2.5-Story
3-Story
Duplex
Townhome
Raised Ranch/Bi-level
Log Home
Manufactured Home
Unknown
Square Footage
Number of Bathrooms
Please Select
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7 or more
Age of Roof
*
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975 and Before
Roof Material
Please Select
Composition Shingles
Architectural Shingles
Wood Shake
Clay Tiles
Metal/Steel
Unknown
Age of HV/AC
Please Select
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
Foundation Type
Please Select
Basement
Slab
Crawl Space
Stilts/Pier/Beam
Unknown
What % of the basement is finished?
Please Select
0%
25%
50%
75%
100%
Unknown
Garage Stalls/Type
Please Select
None
Carport
Attached - 1 Stall
Attached - 1.5 Stall
Attached - 2 Stall
Attached - 2.5 Stall
Attached - 3 Stall
Attached - 3.5 Stall
Attached - 4+ Stall
Built-In - 1 Stall
Built-In - 1.5 Stall
Built-In - 2 Stall
Built-In - 2.5 Stall
Built-In - 3 Stall
Built-In - 3.5 Stall
Built-In - 4+ Stall
Detached - 1 Stall
Detached - 1.5 Stall
Detached - 2 Stall
Detached - 2.5 Stall
Detached - 3 Stall
Detached - 3.5 Stall
Detached - 4+ Stall
Other
Number of Fireplaces
Please Select
0
1
2
3
4
5 +
Unknown
Exterior Finishes
Please Select
Brick
Brick - Synthetic/Veneer
Clapboard/Hardboard
Fiber Cement
Metal
Stone/Synthetic Stone
Stucco
Wood - Beveled
Wood - Engineered
Wood - Shake
Vinyl
Unknown
Other
Do you have any pets?
Yes
No
What kind of pets and what breeds?
Have they ever bitten anyone?
Yes
No
Do you have full circuit breakers?
Yes
No
Do you have a sump pump?
Yes
No
Does the sump pump have a backup power source?
Yes, Battery
Yes, Gas
No
Other
Do you have any of the following:
Jewelry, Fire Arms, or Valuable Items
Swimming Pool
Trampoline
At-home Business
Wood Stove
Alarm Systems
Property named in a Trust or LLC
What valuable items do you need coverage for? What are their approximate values?
Please list item, approximate value, and description. Upload any appraisals to documents section.
Swimming Pool Square Feet
Is the pool fenced in?
*
Yes
No
Does the pool have a diving board?
*
Yes
No
Is the trampoline fenced in?
*
Yes
No
Does the trampoline have a net?
*
Yes
No
What kind of at-home business do you run?
Does your business have foot traffic in the home?
*
Yes
No
What kind of alarm system?
Is it monitored 24/7? Is it a Ring camera? Is it for fire or burglary?
What is the name of the trust or LLC?
We may need additional information regarding non-personal entities.
Home Insurance Documents
Browse Files
Drag and drop files here
Choose a file
To help us match coverages, please upload any policy documents you would like. Also include any jewelry appraisals or relevant documents.
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Renters Insurance
Building Type
Please Select
Apartment
House
Townhome
Mobile Home
Other
Requested Contents Coverage Amount
$50,000 Minimum Required
Auto Insurance
Are You Currently Insured
*
Yes
No
Who is your current auto insurance carrier?
Auto Insurance Documents - Current or Most Recent
Browse Files
Drag and drop files here
Choose a file
To help us match coverages, please upload any policy documents you would like.
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Total Number Of Household Drivers (Including yourself and any co-applicants)
*
Please Select
1
2
3
4
5
6 or more...
Include Named Insured, Co-Applicant, and any other members of the household with a license.
Additional Driver 1
First Name
Last Name
Date of Birth - Additional Driver 1
-
Month
-
Day
Year
Date
Driver's License # - Additional Driver 1
Additional Driver 2
First Name
Last Name
Date of Birth - Additional Driver 2
-
Month
-
Day
Year
Date
Driver's License # - Additional Driver 2
Additional Driver 3
First Name
Last Name
Date of Birth - Additional Driver 3
-
Month
-
Day
Year
Date
Driver's License # - Additional Driver 3
Additional Driver 4
First Name
Last Name
Date of Birth - Additional Driver 4
-
Month
-
Day
Year
Date
Driver's License # - Additional Driver 4
Additional Driver 5
First Name
Last Name
Date of Birth - Additional Driver 5
-
Month
-
Day
Year
Date
Driver's License # - Additional Driver 5
Please place additional drivers in the text box below.
Liability Limit Requested
*
Please Select
$300,000
$500,000
$750,000
$1,000,000
Other
Total Number Of Autos to Cover
*
Please Select
1
2
3
4
5
6
7 or more...
Vehicle 1 Year
Vehicle 1 Make and Model
Vehicle 1 VIN:
Vehicle 2 Year
Vehicle 2 Make and Model
Vehicle 2 VIN:
Vehicle 3 Year
Vehicle 3 Make and Model
Vehicle 3 VIN:
Vehicle 4 Year
Vehicle 4 Make and Model
Vehicle 4 VIN:
Vehicle 5 Year
Vehicle 5 Make and Model
Vehicle 5 VIN:
Vehicle 6 Year
Vehicle 6 Make and Model
Vehicle 6 VIN:
Please place additional vehicles in the text box below.
Motorcycle/ATV/UTV Insurance
Total Number Of Motorcycles/ATVs to Cover
*
Please Select
1
2
3 or more...
Vehicle 1 Year:
Vehicle 1 Make and Model:
Vehicle 1 VIN:
Vehicle 2 Year:
Vehicle 2 Make and Model:
Vehicle 2 VIN:
Vehicle 3 Year:
Vehicle 3 Make and Model:
Vehicle 3 VIN:
Please place additional vehicles in the text box below.
Life Insurance
What amount of life insurance would you like?
Please Select
Unsure
$10K - $49K
$50K - $199K
$100K - $249K
$250K - $999K
$1M - $1.9M
$2M +
What kind of life insurance are you looking for?
Please Select
Unsure
Whole Life
Term
Universal
Umbrella Insurance
What amount of umbrella insurance would you like?
Please Select
Unsure
$1 Million
$2 Million
$3 Million
$5 Million
$6 Million +
Why are you shopping for an umbrella?
Please Select
Financial protection
Exposures from work or lifestyle
Risk mitigation
Who provides your auto insurance?
Auto Insurance Policy Number:
Who provides your home insurance?
Home Insurance Policy Number:
Boat Insurance
Total Number Of Boats to Cover
*
Please Select
1
2
3 or more...
Boat 1 Year:
Boat 1 Make and Model:
Boat 1 Hull ID:
Boat 1 Approximate Value:
Boat 1 Length/Size:
Boat 1 Max Speed:
Boat 1 Motor and Trailer Details:
Boat 2 Year:
Boat 2 Make and Model:
Boat 2 Hull ID:
Boat 2 Approximate Value:
Boat 2 Length/Size:
Boat 2 Max Speed:
Boat 2 Motor and Trailer Details:
Boat 3 Year:
Boat 3 Make and Model:
Boat 3 Hull ID:
Boat 3 Approximate Value:
Boat 3 Length/Size:
Boat 3 Max Speed:
Boat 3 Motor and Trailer Details:
Please place additional boats, motor, and trailer information in the text box below.
Business Insurance
What business insurance options are you looking to shop today?
*
Property
Umbrella
Auto
Workers Compensation
General Liability
Professional Liability
BOP
Other
Business Name:
*
FEIN:
Owner Name:
Year Business Started:
Years of Industry Experience:
Number of Employees:
Is the named insured address the same for the business policy?
Yes
No
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Annual Revenue:
Total Annual Payroll:
Website Address:
Services Provided:
Business Insurance - Document Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
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Medicare
When would you like the policy to be effective?
-
Month
-
Day
Year
Date
Part A Effective Date:
-
Month
-
Day
Year
Date
Part B Effective Date:
-
Month
-
Day
Year
Date
Preferred Pharmacy:
Drug List:
Provide name, frequency, and dosage.
Current Dental Insurance, If Applicable:
Current Vision Insurance, If Applicable:
Other
What kind of insurance are you looking for?
Any other details to assist us in providing coverage?
Additional coverages or higher limits may be available.
If interested, please contact us.
Please verify that you are human
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